ELDER ABUSE, NEGLECT & COGNITIVE …...•A 2010 study found that 47% of participants with dementia...

ELDER ABUSE, NEGLECT & COGNITIVE IMPAIRMENT :

WHAT DO WE DO?

KRIS FREDRICKSON, MSW, LICSW

CLINICAL SOCIAL WORKER

GERIATRIC RESEARCH, EDUCATION AND CLINICAL CENTER‐ PSHCS

206.764.2188,

[email protected]

LEARNING OBJECTIVES

Kris Fredrickson, LICSW. Seattle VA Geriatric Services 3.5.19

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• Discuss the definition of vulnerable adult and therole of Adult Protective Services.

• Identify the types of abuse, neglect andexploitation.

• Explain interventions available for older adultsexperiencing abuse, neglect or exploitation.

• Identify risk factors and caregiver profiles.

• Discuss professional responsibility of mandatedreporters.

Elder Abuse and Neglect (Frederickson), NW GWEC Winter 2019 1

STATS AND FACTS

• “…Between 1 and 2 million Americans age 65 or older have been injured,

exploited, or otherwise mistreated by someone on whom they depended for

care or protection.” Elder mistreatment: abuse, neglect and exploitation in an aging America. 2003. Washington, DC: national research council panel to

review risk and prevalence of elder abuse and neglect.

• A comprehensive review article found the prevalence of elder abuse to be

approximately 10% including physical abuse, psychological or verbal abuse,

sexual abuse, financial exploitation, and neglect.Lachs, m., & Pillemer, K. (2015). Elder abuse. New England journal of medicine, 373, 1947–56.

Doi:10.1056/nejmra1404688

• A 2010 study found that 47% of participants with dementia had been

mistreated by their caregivers. Of them, 88.5% experienced psychological

abuse, 19.7% experienced physical abuse, and 29.5% experienced neglect.Wiglesworth, a., Mosqueda, L., Mulnard, R., Liao, S., Gibbs, L., & Fitzgerald, W. (2010). Screening for abuse

and neglect of people with dementia. Journal of the American geriatrics society, 58(3), 493–500. Doi:

10.1111/j.1532‐5415.2010.02737.X


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• The direct medical costs of injuries are estimated to contribute

more than $5.3 billion to the nation’s annual health expenditures. Dong, x.Q. (2005). Medical implications of elder abuse and neglect. Clinics in geriatric medicine, 21(2),

293–313.

• Because older victims usually have fewer support systems and

reserves—physical, psychological, and economic—the impact of

abuse and neglect is magnified, and a single incident of

mistreatment is more likely to trigger a downward spiral leading to

loss of independence, serious complicating illness, and even death. Lachs MS, Williams Cs, O'Brien S, Pillemer Ka, Charlson Me. The mortality of elder mistreatment. Journal of the

American Medical Association. 1998;280(5):428–432

• The Administration on Aging expects the over 65 population to

double from 2000 to 2030 with OA being 19% of the population.


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THERE IS ALWAYS A

LOT MORE GOING ON

THAN WE EVER KNOW

ABOUT.


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1:24


ELDER ABUSE DEFINITION

• “The willful action or inaction that inflicts injury,

unreasonable confinement, intimidation, or

punishment on a vulnerable adult. In instances of

abuse of a vulnerable adult, who is unable to express

or demonstrate physical harm, pain, or mental

anguish, the abuse is presumed to cause physical

harm, pain, or mental anguish. Abuse includes sexual

abuse, mental abuse, physical abuse, and exploitation

of a vulnerable adult.” RCW 74.34.020

•


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WHO IS A “VULNERABLE ADULT?”A) sixty years of age or older with inability to care for themselves OR

(b) incapacitated RCW11.88.127 OR

(c) developmental disability RCW 71A.10.020 OR

(d) admitted to any facility OR

(e) receiving licensed home health, hospice care agencies RCW70.127 OR

(f) receiving services from DSHS contracted provider OR

(g) self‐directs their own personal medical, nursing, or home health aide

services RCW 74.39.


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TYPES OF ABUSE AND EXPLOITATION

• Physical abuse: intentional infliction of physical harm

• Psychological abuse: intentional infliction of mental harm and/or psychological distress Including violations of basic rights protected under state and federal law

• Sexual abuse: any sexual activity for which the person does not or can not give consent.

• Financial/material exploitation: misuse, misappropriation, or exploitation of the person’s possessions, property and/or monetary assets.

Kris Fredrickson, LICSW. Seattle VA Geriatric Services 3.5.19 9

NEGLECT

•Active neglect: the CG fails to meet their obligation to care for the

•Passive neglect: unintentional. •Self neglect: failure to meet their own


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SELF NEGLECT

Q: If an individual is not found to be legally “incompetent” (by a judge) but chooses to neglect their personal health or safety or refuses appropriate care, is this self neglect and does it warrant reporting and intervention?

Q: What does self neglect look like?


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RISK FACTORS

• Female

• Physically/ medically disabled

• Diagnosed with dementia, MH issues, and/or

substance abuse

• Socially isolated/unmarried/divorced

• Live with caregiver in their home

• History of previous trauma

o ? Age


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Acierno R., Hernandez, M.A., Amstadter A.B., Resnick H.S., Steve K., Muzzy W., & Kilpatrick D.G. (2010). Prevalence and correlates of emotional, physical, sexual, and financial abuse and potential neglect in the united states: the national elder mistreatment study. American Journal of Public Health 100(2), 292–297. doi: 10.2105/AJPH.2009.163089


MRS. A

• 92 yo African American, WWII Veteran, divorced for 30 years

• Diagnoses‐Alzheimer’s Disease, Arthritis, and Stage 3 Kidney

Disease, Macular Degeneration. History of Falls.

• 65 yo son lives with her and her adored toy poodle “killer” and

helps with her ADLs and IADLs including money mgmt and

cooking

• Mrs. C says she is losing weight because she doesn’t eat very

much and doesn’t like the food.

The son brings her to clinic and wants a pain meds refill.


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POTENTIAL INDICATORS OF ABUSE & NEGLECT

Neglect

• Victim: lack of personal care

• Perpetrator behavior

Emotional/psychological abuse

• Victim



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POTENTIAL INDICATORS AND SYMPTOMS OF ABUSE CONTINUED

Physical/Sexual abuse

• Victim



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POTENTIAL INDICATORS AND SYMPTOMS OF ABUSE

Material or financial abuse

• Victim symptoms/indicators


o Use of “Undue Influence”

• Scams‐ “sweetheart,” lottery, wire money, driveway/roof

repair, sweepstakes, IRS, grandchild needs money or in jail…

contact the federal trade commission and AARP for more

info.

Https://www.Consumer.Ftc.Gov/scam‐alerts

Http://www.Aarp.Org/AARP/fraud


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CASE‐ CAGE

2013

• Woman restrains 89 yo

mother in cage‐like

structure boyfriend made

• “we weren’t trying to harm

HER... Keeping her

safe…was an ill‐advised

attempt to help my

parents… to keep the

family together…”


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WHO ARE THE PERPS?

Perpetrators

• adult children/spouses

• Male

• history of past/current substance abuse, mental or physical health problem

• history of trouble with the police

• socially isolated

• unemployed/financial problems

• experiencing major stress.

• Lachs, m., & Pillemer, K. (2015). Elder abuse. New England Journal of Medicine, 373, 1947–56. Doi: 10.1056/nejmra1404688


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• In a study of 4,156 older adults, family

members were the most common perpetrators

of financial exploitation of older adults (FEOA)

(57.9%), followed by friends and neighbors

(16.9%), followed by home‐care aides (14.9%)Peterson, j., Burnes, D., Caccamise, P., Mason, A., Henderson, C., Wells, M., & Lachs, M. (2014). Financial

exploitation of older adults: a population‐based prevalence study. Journal of general internal medicine, 29(12), 1615–23. Doi: 10.1007/s11606‐014‐2946‐2

Kris Fredrickson, LICSW. Seattle VA Geriatric Services 3.5.19 19

POTENTIAL CONTRIBUTORS

CAREGIVER STRESS:

• Inadequate coping skills

• Feeling without help or options

• “Current research has since determined

that what is most often

underlying an abuser’s behavior is

not caregiver stress, but is in

fact entitlement thinking patterns

and a desire to exert and

maintain power and control over a

victim.”

Http://www.Ncall.Us/dynamics‐of‐abuse‐in‐later‐life/


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CONTRIBUTORS TO ELDER ABUSE CONTINUED

Dependency in relationship to the older/vulnerable person:

• Dependency < CG resentment and stress<

Intergenerational transmission of violence:

• Abused as children by victim now has potential to participate in a

cycle of violence in response to conflict, anger, or tension or as a

form of “payback”


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CULTURE AND ABUSE

Societal attitudes that make it easier for abuse to occur and continue without

detection or intervention:

• Devaluation/lack of respect for older/vulnerable adults and women.

• Older/vulnerable regarded as , non productive, disposable, a drain on resources.

• What goes on in the home/family is “private”

• Shame and embarrassment PREVENT revealing abuse.

• Language/cultural barriers

• what is considered "abuse" varies across diverse communities.

• Religious/ethical belief systems not considered abusive.

• Older/vulnerable and women’s basic rights are not honored=not realizing they

are being abused.


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HOW TO PREVENT ABUSE

• Education • Social contact and support • Treatment• Multidisciplinary collaboration• Research


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BARRIERS TO ASSESSMENT

• Is it my responsibility to assess? Who’s job is it anyway?

• How much time with it take?

• What questions should you ask?

• You can’t assess a person with dementia.

• I don’t want their rights limited if I intervene.

• Abuse is rare, probably a physical problem. It’s probably (a medical conditions that might mimic abuse).

• They should have a cognitive eval first? Mini Cog, MOCA, SLUMS

• Does her AD diagnosis mean she isn’t “competent?”

• Should we believe her report considering her cognition?

• If I ask the questions will it offend the patient?

• Should I talk to the patient with the caregiver present? What if they want to be there?


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ASSESSMENT

• Talk to Victim

• Safety

• Talk to suspected abuser: Discuss “appearance of impropriety.”

• “Decisional Capacity?”

• Assess ADL /IADL abilities

REFERRALS

• Recommend community resources

• Discuss a VA Fiduciary for VA income or Payee for Social Security.


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RESPITE

• Temporary rest/“time off”

• Http://www.Lifespanrespitewa.Org/find-respite-care/elders/

• What pays for it? VA/ DSHS-Medicaid, State

• Senior Services in counties and cities

• 211

• Senior centers, church, gyms,

community centers, family


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INTERVENTIONS

POWERS OF ATTORNEY

• Designate trusted person(s)

• “Durable”

• Revocable

• Witnessed and notarized

• Health care documents

• https://www.Washingtonlawhelp.Org/resource/questions-and-answers-on-

powers-of-attorney?Ref=s4jvq#ib433c635-f80b-4f7b-87d2-4f288b60a0c3

• 211 and www.Resourcehouse.Com/win211


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INTERVENTIONS

VULNERABLE ADULT PROTECTION ORDERS

Protection from:

• Abandonment

• Abuse

• Isolation

• Similar to No Contact Order


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VULNERABLE ADULT PROTECTION ORDERS CONTINUED

https://www.Courts.Wa.Gov/forms/?Fa=forms.Contribute&formid=#formanchor

• Petition may be brought by any “interested person"

• Interest in welfare

• A good faith belief intervention is necessary

• The victim is unable to protect their own interests

• Permission from victim not necessary and the court then

decides if it should be pursued.

• Order of protection may last up to 5 years


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INTERVENTIONSGUARDIANSHIP

• Process (RCW 11.88.010.)

a) petition given

b) appointment of a “guardian ad litem”

c) statement from a physician or psychologist

d) hearing in Superior court

e) court appoints guardian of person, estate, limited or full

• What can’t a guardian do? Place a person in a nursing home or psychiatric facility

without court order.

• Costs: $3000‐$5000 for court, lawyer and guardian ad litem fees

• 3‐6 mo

• Public guardianship


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MANDATORY REPORTERS

We All Are!

If in doubt‐Report!

Any Social Service, law enforcement, school, health/mental health/ medical care provider and medical examiners, Christian science practitioners. Per RCW 74.34.035


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Required by law to report suspected abuse, neglect or exploitation of vulnerable adults to DSHS or police:

STEPS TO REPORT

Call 911 and DSHS if there is a reason to suspect (RCW 74.34.035)…

• APS (DSHS )‐county the Victim lives, if they are living in their own dwelling and not in a residential care facility.

‐National 1.866.ENDHARM

‐King county 1.866.221.4909/ FAX: 206.626.5705 ‐Skagit 360.676.6749

‐Snohomish county 1.800.487.0416 ‐Pierce county 1.800.442.5129

https://www.Dshs.Wa.Gov/altsa/home‐and‐community‐services/adult‐abuse‐and‐prevention

• Call the long term care ombudsman 1.800.562.6078/fax: 253-815-8173

If the pt is living in a nursing home, boarding home/ALF, or adult family home.

Https://www.Waombudsman.Org/

[email protected]


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WHAT HAPPENS AFTER YOU CONTACT APShttps://www.washingtonlawhelp.org/resource/aps‐investigations‐and‐findings

APS will take the report, investigate if APS has jurisdiction and if the adult is considered avulnerable adult. If so they will:

• conduct a home visit, usually unannounced• interview other individuals • offer protective services • law enforcement may be called upon to investigate.

What happens next?If “substantiated” APS may

• assign a case manager to determine care services needs • seek emergency resources and ensure safety• help get an emergency protective order• refer for legal assistance and work with the Attorney General’s office

The vulnerable adult has the right to make his/her choices and has the right to refuse or change their mind and withdraw consent for any interventions or assistance from APS.


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WHO ELSE TO CONTACT

• Domestic Violence Resources:

‐National domestic violence hotline at 1.800.799.SAFE (7233) or TTY 1.800.787.3224.

‐Domestic Abuse Women’s Network (DAWN) 24‐hour crisis hotline: 425.656.7234

‐New Beginnings 24‐hour help line: 206.522.9472

• Sexual Assault and Traumatic Stress Center

401 Broadway Seattle, WA 98104

206.714.1600/ 206.744.1616 TDD/ 206.744.1614 FAX

• Area Agency on Aging: Aging and Disability Services‐Seattle/King County

Help for older adults to plan and find long term care.

206.684.0660 or toll free:1.888.435.3377


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MORE RESOURCES

• Sound Generations:

Senior Information and Assistance and Family Caregiver Support Program

206.448.3110 Or 1.888.435.3377 Or 1.888.4.ELDERS

https://www.Soundgenerations.Org/

• Division of Fraud Investigations (DFI) Washington State Welfare Fraud Hotline:

1.800.562.6906

• Federal Trade Commission‐ https://www.Consumer.Ftc.Gov/

Information and Written Materials About Scams, Fraud And Identity Theft and What To

Do About It.

• Dept Of Social And Health Services: Home And Community Services (DSHS)

Help For Adults Who May Need Benefits To Help Pay For Supervised Care.

206.341.7750 Or 1.800.346.9257 TTY: 1‐800‐833‐6384

• National Center On Elder Abuse http://www.Ncea.Aoa.Gov

Most Comprehensive Online Resource Available On Elder Abuse Kris Fredrickson, LICSW. Seattle VA Geriatric Services 3.5.19

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REFERENCES

• Acierno R., Hernandez, M.A., Amstadter A.B., Resnick H.S., Steve K., Muzzy W., & Kilpatrick D.G. (2010). Prevalence And Correlates Of Emotional, Physical, Sexual, And Financial Abuse And Potential Neglect In The United States: The National ElderMistreatment Study. American Journal Of Public Health 100(2), 292–297. Doi: 10.2105/Ajph.2009.163089

• Dong, X.Q. (2005). Medical Implications Of Elder Abuse And Neglect. Clinics In Geriatric Medicine, 21(2), 293–313.

• Elder Mistreatment: Abuse, Neglect And Exploitation In An Aging America. 2003. Washington, DC: National Research Council Panel To Review Risk And Prevalence Of Elder Abuse And Neglect.

• Lachs M & Pillemer K. (2015). Elder Abuse. New England Journal Of Medicine, 373, 1947–56. Doi: 10.1056/Nejmra1404688

• Lachs M, & Pillemer, K. (2015). Elder Abuse. New England Journal Of Medicine, 373, 1947–56. Doi:10.1056/Nejmra1404688

• Lachs MS, Williams Cs, O'brien S, Pillemer Ka, Charlson M. The Mortality Of Elder Mistreatment. Journal Of The American Medical Association. 1998;280(5):428–432

• National Center On Elder Abuse. Major Types Of Elder Abuse. US Administration On Aging Web Site. Updated 2007. Http://Www.Ncea.Aoa.Gov/Ncearoot/Main_site/FAQ/Basics/Types_of_abuse.Aspx

• Peterson J., Burnes D., Caccamise P., Mason A., Henderson C., Wells M., & Lachs M. (2014). Financial Exploitation Of Older Adults: A Population‐based Prevalence Study. Journal Of General Internal Medicine, 29(12), 1615–23. Doi: 10.1007/S11606‐014‐2946‐2

• Wiglesworth, A., Mosqueda L., Mulnard R., Liao S., Gibbs L., & Fitzgerald W. (2010). Screening For Abuse And Neglect Of People With Dementia. Journal Of The American Geriatrics Society, 58(3), 493–500. Doi:10.1111/J.1532‐5415.2010.02737.X

•


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ELDER ABUSE, NEGLECT & COGNITIVE …...•A 2010 study found that 47% of participants with dementia...

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